Objective: This study serves as an early exploration of the benefits and limitations of the flipped classroom (FC) teaching strategy, as perceived by oral radiology undergraduate dental students, as well as of the resistance and challenges expected when applying it. Materials and Methods: A video lecture was presented to 50 oral radiology students 2 days before the lecture date as FC preparation, after which class time was used for exercise questions and discussion. A questionnaire with 5-point Likert scale and two open questions was used to measure students' perspectives toward FC. Results: The main concerns about FC reported by the students (54%) were lack of time for preparing for class and a high comfort level with traditional lectures. The main positive perspectives were that FC provides more time for questions and discussions (60%), students were motivated to learn more about FC (50%), and students were willing to use videos and technology in the learning process (60%). Conclusions: Students' perceptions about FC were reserved because of the insufficient amount of time they had to prepare for it and because they were more accustomed to traditional-style lectures. Nevertheless, students were willing to learn more about FC and how to use technology to improve the learning process. If FC was to be adopted, further faculty development would be needed to better enhance the learning process for oral radiology students.

Traditional teaching methods for undergraduate radiology students have focused on delivering a substantial amount of information with little room for interaction between student and instructor. Presenting educational materials in large classroom settings may not, however, be the best approach for sharing knowledge, capturing student interest in learning, or helping students master the problem-solving skills needed in the field of radiology.[1] In addition, numerous studies have reported that, besides overlooking the fundamental conventions of radiology, dentists also fail to strictly abide by the laws related to radiograph application in the countries in which they practice.[2],[3],[4] Improper radiographic techniques – failure to protect patients from excessive exposure, incorrect use of cone indicators, insufficient film development, and nonstandard disposal of waste products – can contribute to higher radiation doses, inadequate radiograph quality, and environmental harm.

Inadequate preparation of undergraduate students has been proposed to account for these shortcomings,[5] with the education of dental students, in particular, coming under scrutiny in terms of changes to the didactic model.[6],[7] Although some educational institutions have started incorporating interactive problem solving and team-based learning into their programs, the process has been slow, and thus most medical schools still use traditional lectures.[8]

The flipped classroom (FC) model is an integrated method for learning in which students review content ahead of the classroom session and teachers use class time for active learning.[9] Preclass assignments form the basis of core knowledge, which active learning then solidifies by delivering it in an interactive and appealing form.[10] The FC model is thus considered an apt approach to medical education.

One research study showed that the FC model is more effective than the traditional model for achieving learning objectives.[11] Other studies, however, reported that the FC approach may be less beneficial than the conventional classroom approach. Students with little familiarity with the FC design could perceive it as a negative learning experience. For this reason, FC courses should be designed to take into account the learner's educational needs. It is, therefore, important to explore which elements of an FC course influence the learning experiences of the students and ultimately their learning outcomes.[10],[11],[12]

Due to its image- and case-based format, as well as its movement toward web-based teaching, radiology is a good fit for the online delivery of course materials.[13],[14] Teaching radiology represents an opportunity to use the FC feature as an advantage by providing online resources for classroom preparation and reserving lecture time for additional class activities. Although the FC approach has been favorably regarded by students in other programs, its perception among dental students is less clear.[15] This study, therefore, explored the perceptions of oral radiology undergraduate dental students about the benefits and limitations of FC learning, as well as the resistance and challenges expected with its application.

Materials and Methods

This survey study was conducted in Al Madinah Al Munawarah, Saudi Arabia, in 2017. It included 50 4th year undergraduate dental students attending the oral radiology class.

The Taibah University, College of Dentistry Research Ethics Committee approved this study in September 2017.

A ½ h video lecture was sent to all oral radiology students 2 days before the lecture, which also included reading the material, and class time was used for exercise questions and discussion groups guided by the instructor.

After the class, a feedback questionnaire was distributed to the 50 students who attended the class to measure their perceptions about FC. The questionnaire was modified from a previous study,[16] with ten 5-point Likert scale questions, where 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree. In addition, there were two open questions.

Quantitative and qualitative analyses of students' answers measured student perceptions and contrasted hypotheses to determine the extent to which students react positively or negatively to general elements of the FC.

The descriptive analyses with frequencies, percentages, and graphs were developed using Microsoft Excel software, and the responses to the open question were summarized, coded, and presented as a graph.

Results

The response rate was 100%, as all 50 students attending the class completed the Likert scale feedback questionnaire. They were all female students, 30 of them (60%) having some knowledge about FC before the class, the rest (40%) having been introduced to FC by the instructor.

Only 21 students (42%) watched the online video prepared by the instructor before the class. Among the students who provided reasons for not watching it, the most frequent response was a shortage of time or short notice, with a few indicating that they like live lectures. More than half of the class members (54%) were strongly satisfied or satisfied with the traditional way of learning dentistry, as seen in [Figure 1]. A large portion of students (34%) were neutral about traditional learning, and only 12% were not satisfied.

Figure 1: Percentage of students' responses to the question: Are you satisfied with the traditional way of learning in dentistry?

In answer to the question about whether FC is more engaging than the traditional classroom, 42% of the students were neutral, whereas 34% agreed or strongly agreed that FC is more engaging [Figure 2]. Most students (70%) agreed or strongly agreed that FC needs a lot of improvement [Table 1] and [Figure 3]. Less than half of the students (40%) agreed or strongly agreed that FC allows greater opportunities to communicate with other students, whereas 40% were neutral. Most of the students (60%) agreed or strongly agreed that FC allows more time for asking questions, whereas 26% were neutral and 14% disagreed or strongly disagreed [Figure 4]. Half of the students were motivated to learn more about FC, and 28% were neutral [Figure 5]. More than half of the students (60%) liked watching the lesson on video, whereas 22% were neutral and 18% disagreed or strongly disagreed with watching the lesson this way.

Figure 2: Percentage of students' responses to the statement: The flipped classroom is more engaging than the traditional classroom lecture

Only 32% of the students were willing to spend time preparing for the class, whereas 38% were neutral and 30% disagreed or strongly disagreed that they were willing to do so. Most students (64%) agreed or strongly agreed with using technology for learning, 26% were neutral, and 10% disagreed or strongly disagreed [Table 1]. Most students (70%) agreed or strongly agreed that FC needs a lot of preparation from the instructor, with 20% selecting neutral and 10% disagreeing or strongly disagreeing.

For the open question regarding suggestions about other ways to improve oral radiology learning, most students suggested keeping the traditional live lectures but making them shorter and to the point and leaving the rest of the lecture time for more discussion and practical exercise. Only a few said that FC was amazing and helped them to think critically; on the other hand, they were afraid that there was not enough time between preparing for all of the exams and quizzes, spending time in the clinic, and getting ample sleep or rest. The most frequent suggestions by students regarding oral radiology classes are summarized in [Figure 6].

Figure 6: Percentage of students who made the most common suggestions about oral radiology classes

Assessing the effectiveness of the FC model is a valuable step in developing a better understanding of its potential use in the education of graduate students. To experience success with this novel teaching approach, these students must complete the assigned readings and diligently review the preparatory material (video lectures) before attending class.[17]

In this study, only 42% of the students did their assignment and viewed the preparatory material. This limited interaction with the prepared students may have been the reason that 42% of the students gave a neutral response regarding FC engagement and 24% disagreed or strongly disagreed. The 34% students who agreed or strongly agreed that FC is engaging are probably the students who were prepared and able to interact. Beyond that, most of the students were assertive about not changing the learning method, stating that they preferred the traditional classroom, 54% being satisfied or strongly satisfied with traditional classroom teaching in dentistry and 34% feeling neutral about it. This result was contrary to that from a study by Miller and Metz,[18] where it was shown that students' perspectives about the effectiveness of the traditional classroom were significantly less favorable than those of the faculty. However, a high percentage of students (70%) in the current study agreed or strongly agreed that the FC teaching method needs improvement. This is logical since in our university only traditional lecturing has been pertained, raising the issue of whether new teaching methods need to be applied and improved, including those designed for FC. Researchers and educators should requisite valid and reliable instruments to examine these new designs and their potential for improving the learning process.[16]

Only 34% of the students felt that FC helps them communicate with other students. This finding corresponds to that reported in a study by Murray et al.,[19] who found that replacing face-to-face lectures with prerecorded videos may reduce interaction with staff and peers. Other factors that contributed to the response about communication from students in the current study could have been the room setting, the large class size, the ratio of 50 students to 1 instructor, and the partially prepared students. A large portion of the students (60%), however, agreed or strongly agreed that FC gives them time to ask more questions. This is in accordance with Murray et al.'s study in which they reported a student's comments on the advantages of FC: “We know exactly what we are doing and any questions can be answered by the tutors”.[19] This seems to be a valuable benefit that students indicated they would like to have.

Half of the students became more motivated to learn more about FC, a finding that is in accordance with the study by Hernández-Nanclares and Pérez-Rodríguez,[16] who reported that >60% of the students felt more motivated to learn about FC, a critical component for engaging students in the course and encouraging their participation in the learning process.

Half of the students in the current study agreed or strongly agreed that they were willing to watch the video, whereas 22% were neutral about it. This response was lower than that in the study by Hernández-Nanclares and Pérez-Rodríguez,[16] in which 70% of the students either liked or strongly liked watching video lessons, but in which 54% of the students presented a neutral position regarding the statement, “I would rather watch a video lesson than a traditional teacher-led lesson”(p7). This response could perhaps be interpreted as students still valuing face-to-face interaction with the teacher.[16]

Only 32% of the students in the current study were willing to spend time preparing for the classroom. This is one of the common resistance issues reported by students,[18] specifically dental students,[10] because of their limited time as a result of the long hours spent training in clinics. The high level of comfort with traditional classroom lectures and lack of time to study FC preparatory materials were also common resistance issues. However, as 64% of the students were willing to use technology for learning, this suggests the potential to develop modified FC-like online educational techniques. Howlett et al.[14] showed that such techniques can be successfully combined with other teaching formats to effectively deliver undergraduate radiology courses. The provision of well-organized links to resources and high-quality images is critical to the successful involvement of radiology students.

In the current study, 70% of the students agreed or strongly agreed that FC requires a lot of preparation by the instructor, in accordance with the study by Miller and Metz,[18] who found that high percentages of faculty members (44% of respondents) and students (91% of respondents) cited major concerns regarding the time required for developing materials (faculty members: 33% and students: 29%) and the lack of training (faculty members: 22% and students: 53%).

The main concerns about FC reported by the students in the current study were the lack of time available for watching videos or for reading the preparatory material before the class, a high level of comfort with traditional classroom lectures, and lack of time for the instructor to develop materials. The main positive perspectives reported by the students included more time being available for questions and discussions, motivation to learn more about FC, and willingness to use videos and technology in the learning process.

One limitation of the study was that because it took a long time to prepare the video and upload it to YouTube, it was delivered to the students on short notice; thus, many of them felt that they had limited time for preparation. If instructors had enough experience in preparing the material and uploading it fast enough, the number of engaged students could increase, as could their interaction and communication in FC. Another limitation was the large number of students in the classroom, which is not an ideal setting for maximal interaction, proper critical thinking, and engagement in FC. Despite this limited setting, however, students were motivated to learn more about FC and how it can allow for more time for questions and practical exercises.

Conclusions

The students' perceptions toward FC were reserved because of the insufficient amount of time they had to prepare and because they were more accustomed to traditional-style lectures. Nevertheless, students were willing to learn more about FC and how to use this technology to improve the learning process. If FC was to be adopted, further faculty development would be needed to better enhance the learning process for oral radiology students.

Acknowledgment

I thank Barbara Every, ELS, of BioMedical Editor, for English language editing.